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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: X.601 E. Hazelton Ave, , -Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'ti_SF.T-V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 and. the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ' Phone 3 C-=51 <br /> Address2�p=xtW Cit Q <br /> Contractor's Name ._._-, _ Lic/n ab Phone7c/ ;-/ 7 r <br /> TYPE OF WORK (Check): _NEW-WELL–/P;-----DEEPEN-/% RECONDITION / / AESTAUCTION-/-7. - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TAN ] SEWER LINES PIT PRIVY �. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \7� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \y} <br /> Industrial <br /> Tool Dia. of Well Excavation <br /> –�i5omestic/private Drilled Dia. of Well Casing _L-- ,.;. _ <br /> Domestic/public Driven Gauge of Casing "E" <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 4 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> / <br /> PUMP REPAIR: / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED - �. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY PATE ( Q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION- <br /> / PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE d-1 - fid INSPECTION BY DATE <br /> CALL FOR A GROUT 9INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTIOi . <br /> E H 1426 7/72 1M <br />